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KHARKIV REGIONAL HOSPITAL
DEPARTMENT OF INTENSIVE CARE AND TOXICOLOGY
KWADWO SARFO KANTANKA
(MENTOR – PROF. U FESENKO)
HELLP SYNDROME: A CASE
REPORT AND MANAGEMENT
DEFINITION
It is a syndrome resulting from
microvascular endothelial activation and
cell injury characterised by hemolysis,
elevated liver enzymes and low platelet
count.
RISK FACTORS
Maternal age older than 34 years
Multiparity
White race or European descent
History of poor pregnancy outcome
CLASSIFICATION
TENNESSEE CLASSIFICATION Based on laboratory criteria
1. Platelet count ≤ 100 x 109/L
2. AST ≥ 70 IU/L & LDH ≥ 600 IU/L
3. Hemolysis on peripheral smear
Partial HELLP Full HELLP
Any 2 of 3 criteria All of 3 criteria
MISSISSIPPI CLASSIFICATION Class
1 Platelets ≤ 50•109/L
AST or ALT ≥ 70 IU/L
LDH ≥ 600 IU/L
2 Platelets ≤ 100•109/L ≥50•109/L
AST or ALT ≥ 70 IU/L
LDH ≥ 600 IU/L
3 Platelets ≤ 150•109/L ≥ 100•109/L
AST or ALT ≥ 40 IU/L
LDH ≥ 600 IU/L
CASE REPORT
A 32-year-old primipara, gravida III, was admitted to
the hospital at 34-35 weeks of gestation. She
presented with
Nausea &vomiting
abdominal pains for 3 hours
edema for 1 month
The two previous pregnancies ended with
spontaneous abortion.
Vaginal examination revealed
cervix opening of 2 cm
hemorrhage from vagina and
Cephalic (head) presentation
BP=120/80 mmHg
Initial Laboratory data:
Hb = 85g/l,
Ht=0,26
RBC to 2,88x1012/L,
Leucocyte up to 9,9x109/L
Proteinuria - 8,5 g/L
Urgent caesarean section was performed with the
delivery of a still male fetus at 34-35 weeks of
gestation, BW=2200g and L=48 cm.
complete placenta abruption with evacuation of 500 ml
of blood from the uterus.
On examination of the uterus two apoplectic regions 2
cm in diameter were found. Curettage of the uterus
was performed.
Total intra-operative blood loss = 1000 ml.
Parameter Value in patient Normal range
Hemoglobin 57g/l 120-140g/l
Leucocytes 18x109/l 4,0-9,0x109/l
Neutrophiles 82% 47-72%
Platelets 86x109/l 180-320x109/l
ALT 5,4 mmol/l/h 0,1-0,68 mmol/l/h
AST 3,3 mmol/l/h 0,1-0,45 mmol/l/h
1st post-operative day lab data (district hospital)
The patient was transported to Regional hospital in critical
condition:
medical sedation
artificial ventilation
BP- 180/100 mmHg
Pulse rate – 98/min
CVP – 18 cm H2O
Anasarca
Nasal bleeding
The laboratory results of the patient revealed:
Progressing anaemia
Leucocytosis
Increased creatinine
LDH - 6388 U/L (norm: 298-531 U/L)
0
1000
2000
3000
4000
5000
6000
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
ALT
& A
ST
le
ve
l (U
/L)
Number of days
DAILY LEVELS OF AST & ALT IN THE PATIENT
AST
ALT
0
50
100
150
200
250
300
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
P
L
T
c
o
u
n
t
Number of days
DAILY PLATELET COUNT
Systolic Blood Pressure: max and min (mm Hg)
0
20
40
60
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140
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180
200
1 day
2 day
3 day
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systolic BP max
systolic BP min
Diastolic Blood Pressure: max and min (mm Hg)
0
20
40
60
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100
120
1 day
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6 day
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diastolic BP max
diastolic BP min
Pulse rate: max and min (bits/min)
0
20
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60
80
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160
1 day 2 day 3 day 4 day 5 day 6 day 7 day 8 day 9 day 10 day 11 day
PR max
PR min
Central venous pressure (mm H2O)
0
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1 day 2 day 3 day 4 day 5 day 6 day 7 day 8 day 9 day 10 day 11 day
CVP
Urine output (ml/24h)
0
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1 day
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urine output
Instrumental investigation:
Ultrasound showed a 110x75 mm infarction area in the
right lobe of liver.
Fibrogastroscopy revealed multiple stress ulcers.
Selective carotid angiography with contrast revealed
pathological hyper-vascularization of nasopharyngeal
region from the upper maxillary and medial meningeal
arteries. Endovascular embolization was provided to stop
severe nasal bleeding.
It was also noticed in the patient after endovascular surgery:
Sensory motor aphasia
Right sided hemi-paresis
Ischemic stroke in the left medial brain artery on MRI.
Based on the laboratory criteria, the patient was classified
according to:
Mississippi classification – Class 1 HELLP Syndrome
Tennessee classification – Complete HELLP syndrome
MANAGEMENT Three major options for the management severe preeclampsia
and HELLP syndrome:
Immediate delivery which is the primary choice at 34
weeks' gestation or later.
Delivery within 48 hours after evaluation, stabilization of
the maternal clinical condition and Steroid treatment. At 27
to 34 weeks of gestation, this option appears appropriate
and rational for the majority of cases.
Expectant (conservative) management with Steroid
treatment for more than 48–72 hours may be considered in
pregnant women before 27 weeks' gestation.
TREATMENT In the treatment of the patient, 25 drugs and 53 drugs
were used at the district and regional hospital respectively.
The medication included:
Fluid infusion therapy, PRBC, FFP, Platelets.
Methylprednisolone
Anti-hypertensive drugs
Anticonvulsants
Novo-Seven
Antibiotics
Lazix
I/V infusions
0
1000
2000
3000
4000
5000
6000
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Hepasol-Neo
refortan 15%
PL
FFP
PRBC
crystalloides
CONCLUSION
The patient recovered with complete neurological
restoration.
HELLP-syndrome has severe complications and
extensive preparation and proper monitoring are
necessary for successful management.
Special thanks to prof. Tkachenko Ruslan
Afanasyevich for consultation in treatment of this
patient!
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